Focusing on Males in the Sub-Saharan African HIV Epidemic: a Win-Win Solution for Men and Women

Why are women more likely to be infected and men more likely to die from HIV?

In 2015, nearly 70% of the 37 million people infected with HIV were living in sub-Saharan Africa. Contrary to HIV infections in Europe, most HIV transmission occurs through heterosexual sex in Africa and the incidence of new HIV infections is higher in women than in men. After infection, and in the absence of treatment, HIV-infected individuals die within an average of eight years. However, if lifelong antiretroviral treatment (ART) is started early after infection, the life expectancy is nearly equal to that of a non-infected person.

Enormous progress has been made over the past 15 years in scaling up ART and reducing mortality in sub-Saharan Africa. However, men are still more likely to die from AIDS than are women.

Why are women more likely to be infected and men more likely to die from HIV? We know that men are less likely to be tested for HIV than are women and, when they are finally diagnosed, they are more often in a late stage of AIDS that is less responsive to ART. Additionally, after an HIV diagnosis, more women start and remain on ART than do men. Late HIV diagnosis and poor retention in ART thus increase mortality in HIV-infected men. Furthermore, the untested and untreated men continue to transmit HIV to their partners. Such gender differences may contribute to fueling the increased incidence of HIV in women and high AIDS mortality in men.

Masculine gender norms (...) can create barriers for men to seek HIV testing and engage in care

How is it that after a decade of well successful programmes there is still a lack of specific institutional support for male-tailored HIV testing and care? When the implementation of ART programmes started in sub-Saharan Africa in 2004, priority was given to HIV testing for women in reproductive age and prevention of mother-to-child-transmission. In 2013, the implementation of the World Health Organization’s recommendation of lifelong ART for all pregnant women, known as the B+ initiative, gave women multiple opportunities to initiate ART. This is particularly true in sub-Saharan African countries where women have an average of 5-6 children. These programmes have been extremely successful in reducing mother-to-child transmission of HIV and extending women’s survival. The programmes aimed at men have mainly promoted benefits for their partners and children rather than for their own health.  

Promoting positive male engagement in health may be just as important as maintaining programmes for HIV prevention and care in women and children

Although we may not be aware of the power of societal gender norms on a daily basis, they contribute to shaping socially acceptable notions of masculinity and femininity. In many areas of the world, institutions operate within traditional societal gender norms which can be simplistically summed up as women are vulnerable and men are self-sufficient. It is relatively easy to see how masculine gender norms such as perceived manliness, dominance, self-sufficiency and risk-taking can create barriers for men to seek HIV testing and engage in care.

Promoting positive male engagement in health may be just as important as maintaining programmes for HIV prevention and care in women and children. To this end, international policies and programmes have begun to promote male-tailored support for HIV testing and care in sub-Saharan Africa. This includes work place and community HIV testing, circumcision and male-friendly clinic hours. Maybe a more difficult but equally important task is that of tackling harmful gender norms which increase health risks in both men and women. This is often addressed in women through education and empowerment programmes.

It is time to revisit the concept of masculinity and empower men to take control of their health and seek help when neede

However, there have only been scattered efforts in sub Saharan Africa to shift male norms to assimilate the idea that needing support is not incompatible with male identity. It is time to revisit the concept of masculinity and empower men to take control of their health and seek help when needed. Incorporation of male-oriented health programmes in high HIV prevalence regions of sub-Saharan Africa could be a win-win solution. Fewer men would die of AIDS and fewer women would contract HIV.